The Ethics of Self-Care

Excerpts from The Ethics of Self-Careby Craig Irvine

The medical academy’s primary ethical imperative may be to care for others, but this imperative is meaningless if divorced from the imperative to care for oneself. How can we hope to care for others if we, ourselves, are crippled by ill health, burnout, or resentment? The self-care imperative, however, is almost entirely ignored by medical academicians and professional ethicists. Indeed, biomedical ethics focuses almost exclusively on the application of universal ethical principles to the treatment of patients and the protection of research subjects, discounting, even hindering, the introspection essential to the practice of ethical self-care. If we are to heed the self-care imperative, medical academicians must turn to an ethics that not only encourages, but even demands care of the self. We must turn to narrative ethics. Since narrative is central to the understanding, creation, and recreation of ourselves, we can truly care for ourselves only by attending to our self-creating stories. Narrative ethics brings these stories to our attention; so doing, it allows us to honor the self-care imperative.

We are ethically obligated to care for ourselves. This, I believe, is incontrovertible. Our primary ethical imperative may be to care for others, but this imperative is meaningless, empty, if divorced from the imperative to care for oneself. Indeed, we may grant, with Emmanuel Levinas, that the imperative to care for others is the “primordial, irreducible, and ethical, anthropological category” [1, p. 158]. We may even grant that this imperative is so powerful, so fundamental, that one’s response, as Levinas scholar Richard Cohen writes, “goes all the way to giving the very self of the self” [2, p. 294]. Yet I cannot give myself if I have no self to give. I must care for my hands, if I am to lift the fallen; my heart, if I am to love the stranger; my mind, if I am to cure the ill; my eyes, if I am to find the lost, and my soul, if I am to guide them home. No matter how it is conceived—philosophically, theologically, psychologically—the imperative to care for others is always already an imperative to care for myself.

Unfortunately, biomedical ethics focuses almost exclusively on the application of universal ethical principles to the treatment of patients and the protection of research subjects, thus discounting, even hindering, the introspection essential to the practice of ethical self-care. As I will show below, if we are to heed the self-care imperative, medical academicians must turn to an ethics that not only encourages, but even demands care of the self. We must turn to narrative ethics. Since narrative is central to the understanding, creation, and recreation of ourselves, we can truly care for ourselves only by attending to our self-creating stories. Narrative ethics brings these stories to our attention; so doing, it allows us to honor the self-care imperative.

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Community

“Only connect,” E. M. Forster writes in the epigraph to his 1910 novel Howards End [32]. This admonition, I believe, is a vital expression of the self-care imperative. As Bruner puts it, “Everywhere you look, you run into the recognition of the fact that a human plight is never an island unto itself. So, what should you do? You connect” [19, p. 9]. Indeed, Samuel Shem writes, “the primary motivation of human beings is the desire for connection. … [T]he seeds of human misery are planted in disconnections, violations, isolation, and domination, and the core of healthy growth is the movement from isolation toward connection” [33, pp. 43–44]. Since the work of establishing interpersonal connections is fundamental to addressing “human misery,” ethics is nothing if not this interpersonal work: “Perhaps the greatest life-value of ethics,” writes György Lukács, “is precisely that it is a sphere where a certain kind of communion can exist, a sphere where the eternal loneliness stops. The ethical man is no longer the beginning and the end of all things, his moods are no longer the measure of the significance of everything that happens in the world. Ethics forces a sense of community upon all men” [34, p. 57].

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Conclusion

This, then, is the conclusion of my ethics work with physicians and researchers over the past ten years: to honor the self-care imperative, one must attend to one’s self telling narratives. I therefore agree with David Morris that the “goal of narrative bioethics is to get the stories into the open, where we can examine their values, sift their conflicts, and explore their power to work on us” [15, p. 213]. Opening medical academicians to their own stories is crucial to faculty health. To effect this opening, the ethicist must contend with cultural and professional biases that work to keep these stories hidden. As Bruner writes, “The fact of the matter is that if you look at how people actually live their lives, they do a lot of things that prevent their seeing the narrative structures that characterize their lives. Mostly, they don’t look, don’t pause to look” [19, p. 8]. Fortunately, the native ability to see “the narrative structures” of our lives, while underused, is not rare. This ability, in fact, is almost certainly universal.33

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2 Responses to “The Ethics of Self-Care”

I’ve been participating in the Vicarious Trauma Steering Committee at SFGH which has focused on Schwartz Center Rounds and implementing the rounds at SFGH. Of note, when we discussed how to organize, it became obvious that the Grand Rounds model naturally excluded “front line” workers such as nurses and medical assistants due to their 24-hour schedules and limited, unpredictable break time. This led to further discussion about decentralizing the rounds to de-silo front line workers and to encourage greater inclusion. Needless to say, without nurse participation both the nursing narrative and the nursing perspective would go unheeded. FYI.